Goals. Accelerating adoption & exchange of EHRs project. Evaluation Indicators EMR adoption (Hospitals) 20% (100 hospitals)

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1 12 th International HL7 Interoperability Conference Development of an interoperability infrastructure for exchange of electronic health records among hospitals in Taiwan Chien-Tsai Liu Professor, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan Chair of HL7 Taiwan Hilton in the Walt Disney World Resort, FL, May 13,

2 Background Taiwan s Department of Health (DOH) has been promoting adoption of EHRs since DOH has accomplished key milestones that have contributed to the development of EHR interoperability infrastructures. National health smart cards (23 million cards), in 1994 Image exchange center (IEC) for DOH affiliated hospitals (about 40), in 2009 National EHR exchange center (The project for accelerating adoption & exchange of EHR, started

3 Goals Accelerating adoption & exchange of EHRs project Evaluation Indicators EMR adoption (Hospitals) 20% (100 hospitals) 50% (350 hospitals) 80% (400 hospitals) (OK, 163, 30% ) (working) (unknown) EMR adoption (Primary care clinics) 10% (2,000 clinics) (OK, 2413, 25%) 40% (8,000 clinics) 70% (14,000 clinics) EMR exchange (interhospitals) 50 hospitals (10%) 100 hospitals (20%) 300 hospitals (60%) (DMI+RPT ) (delay due to NEEC) (DMI + RPT + LTr) & (DS or PMR) (DMI + RPT + LTr) & (DS or PMR) DMI: medical images; RPT: Radiology reports; LTR: lab tests & reports DS: discharge summaries; PMR: outpatient medication records

4 EHRDC (4 WGs): Clinical, Patient safety; Standards & Evaluation EHR Development Committee EHRPMO: staff team for supporting the EHRDC in planning, coordinating, and auditing EHR projects at national level. Clinical WG Patient Safety WG Standards WG Evaluation WG EHR PMO Established a National EHR Development Committee (EHRDC) & set up an EHR Program Office (EHRPMO) in Nov Implement the National EHR exchange center (NEEC)

5 Standardized EMR templates Four standardized (CDA R2) EMR templates were developed: Medical image & reports: Discharge summary: Laboratory blood tests reports Outpatient Medications

6 Standardized EMR templates Medical image & reports Seqno Field(Chinese) Field(English) Description cardinality 1 Hospital Id [1..1] 2 Inspection Items Code [1..1] Inspection Items Name [1..1] 3 Check site [1..*] 4 Check the number of sheets [1..*] 5 Accession No. [1..1] 6 ID Number [1..1] Chart No. [1..1] Name [1..1] Administrative Sex MFO [1..1] Birth Date YYYYMMDD [1..1] 7 Date of physician-order start care YYYYMMDDHHMM [0..1] Physician-order name [1..1] 8 Date reference lab test sent () YYYYMMDDHHMM [1..1] 9 Diagnosis ICD code [1..*] 10 History of past illness [1..*] 11 Picture [1..*] 12 Records. total () [1..*] 13 Comment [0..1] 14 Date case report exported () YYYYMMDDHHMM [1..1] 15 Provider signing name [1..1]

7 The CDA Header 7 1. ClinicalDocument/code * We defined various image reports e defined CDA Header attributes, as 2. ClinicalDocument/code/translation *Mapping to Taiwan insurance code <translation code=" 33070B" codesystem=" displayname="computered tomography HL7 Taiwan(C. T.)without contrast" />

8 The CDA Header 8 We define CDA Header Participants & ActRelationship, as 1. legalauthenticator\assignedentity\rep resentedorganization Hospital code & name 2. infulfillmentof \ order \ id Order code & description 3. recordtarget Patient information (chart no, SSN, ) 4. componentof\effectivetime Order time 5. componentof\assignedentity\assigne dperson\component \ physician name 6. documentationof\serviceevent\effecti vetime Exam time HL7 Taiwan

9 The CDA Body 9 We define CDA Body sections, as 1. DICOM Object Catalog 2. Physical examination by body areas (LOINC ) 3. History of present illness (LOINC ) Chief complaint (LOINC ) Indications (LOINC ) 3. Diagnosis ICD code (LOINC ) 4. Records. Total (LOINC ) Radiology Study observation (LOINC ) Diagnosis preliminary (LOINC ) Patient Note (LOINC ) 5. Radiology Study recommendation

10 CDA Sample (Image reports) 10 HL7 Taiwan

11 The framework of EHR exchange architecture

12 EHR Gateway Sever (EGS) BNHI Hospital A Patient Indexes Virtual Private Network (VPN) National EHR exchange center (NEEC), DOH Hospital B EHR Gateway Sever (EGS) EMR Repository CPOE Client CPOE Client EMR epository The framework of EHR exchange architecture

13 System operation for exchanging EHR Two working modes for exchanging EMRs under the framework of the NEEC: provision mode retrieval modes.

14 System operation for exchanging EHR Provision mode In the provision mode, a hospital must firstly prepare an EMR confirmed with a CDA R2 templates defined by the EHRDC, then perform digital signature on the prepared EMR, and lastly, upload the EMR to its EGS. After receiving the EMR, the EGS validates the EMR. It will generate an index of the EMR if the validation is correct, and then send the index to the NEEC.

15 System operation for exchanging EHR Retrieval mode 1.Obtain the patient s consent (a signed informed consent document). 2.Log-in the NEEC system by using both the physician s personnel smart card and the patient s health smart card. 3.Query the patient s indexes from where the physician can select an index of the EMRs related to this visit 4.With the selected index the NEEC server can locate the EGS of a hospital where the EMR is stored. The NEEC server performs the retrieval of the EMR, and send the encrypted EMR to the EGS of the hospital where the physician is requesting the EMR**. 5.The requesting hospital can view the EMR with a NEEC

16 System operation for exchanging EHR NEEC viewer

17 More information: DOH EHR Forum Lab tests Medical image report Discharge summary EMR standards registration system HCA Medical Image Exg Center HL7 Certification Center NHI-LOINC mapping DB

18 Thank you Chien-Tsai Liu Professor, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan Chair of HL7 Taiwan Phone: (02) #

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